Prevention of pressure sores

Identify risk on day one. Apply a validated tool – Braden, Norton or Waterlow – on admission to any facility and repeat regularly, combined with a structured head-to-toe skin inspection that specifically includes the heels, sacrum and skin under every device.

Redistribute pressure. Reposition at least 2-hourly on a standard mattress and at least 4-hourly on a pressure-redistributing mattress. Use a 30° lateral tilt rather than full side-lying, keep head-of-bed elevation to 30° or less to limit sacral shear, and float the heels completely off the bed with a pillow under the calf or a heel-suspension boot.

Choose a support surface. Non-powered surfaces are mattresses or overlays filled with air, water, gel or foam; powered surfaces mechanically vary the pressure and cost far more. Specialised foam and sheepskin overlays reduce incidence compared with a standard hospital mattress; the choice between powered and non-powered is not settled. Overlays on the operating table reduce postoperative pressure injuries and should be routine for long operations in the elderly.

Reduce shear and friction. Use slide sheets, hoists and two-person lifts rather than dragging; keep linen taut and wrinkle-free; avoid loose folded skin, which is common in the elderly from loss of subcutaneous fat and dehydration.

Control moisture and incontinence. Clean promptly after every episode with a pH-balanced cleanser, dry gently, and apply a barrier film or cream. Recognise and treat incontinence-associated dermatitis as a separate entity – it is frequently misclassified as a Stage 2 injury.

Moisturise dry skin. Dry sacral skin is itself a risk factor, so regular emollient application is a reasonable preventive measure. No topical agent has been shown superior to any other.

Nutrition and hydration. Refer at-risk patients to a dietitian for a full nutritional assessment. Targets: 30–35 kcal/kg/day, protein 1.0–1.5 g/kg/day, fluid 1 mL/kcal. Nutritional supplements may help but it is not clear which nutrients matter most.

Attack immobility itself. Avoid excessive bed rest, get the patient up for meals, optimise and encourage function, avoid over-sedation, minimise physical restraints, restrictive siderails, catheters and lines – every one of these enforces immobility.

Device care. Inspect the skin under and around all medical devices at least twice daily, reposition or rotate the device, and consider a protective dressing beneath it. Suspect a device-related injury whenever the wound shape mirrors the device.

Multifactorial, multidisciplinary bundles work – exactly as for falls and delirium prevention. But not all pressure injuries are avoidable, particularly at the end of life; a documented prevention protocol must be in place before any injury is declared unavoidable. Latest Updates (2023–present) — three key points

Fourth edition International Guideline (NPIAP/EPUAP/PPPIA, 2025) – the prevention chapters were released first as living online documents using GRADE methodology; the SPIPP checklist distils prevention into five auditable practices: validated risk assessment, prophylactic dressings, support surfaces, repositioning systems and skin care.

Prophylactic soft silicone multilayered foam dressings are now suggested as an adjunct to heel elevation and repositioning (and over sacrum and trochanters) where resources permit – not a replacement for turning. The NPIAP/EPUAP Prophylactic Dressing Standards Initiative is developing performance standards for dressings applied to intact skin.

Sub-epidermal moisture (SEM) and skin temperature measurement are recommended as adjuncts to visual skin assessment, detecting damage before it is visible – of particular value in darkly pigmented skin, where Stage 1 erythema is frequently missed and injuries are therefore diagnosed later and at a higher stage.

Prevention rests on identifying risk, offloading pressure, and controlling moisture, friction and nutrition.

Turn at least 2-hourly on a standard mattress, 4-hourly on a pressure-redistributing mattress.

Limit head-of-bed elevation to 30° to reduce sacral shear.

Heels must be floated completely off the surface, not merely cushioned.

Specialised foam and sheepskin overlays reduce incidence versus a standard hospital mattress.

Theatre-table overlays reduce postoperative pressure injuries.

Dry sacral skin is a risk factor – moisturising is a legitimate preventive intervention.

Incontinence-associated dermatitis is not a Stage 2 pressure injury.

Prophylactic silicone foam dressings are an adjunct to, never a substitute for, repositioning.

An unavoidable pressure injury can only be declared after a documented prevention protocol has been applied.